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!/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0T.,*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 4/-? <br /> 7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local tical.th. District for a' permit to construct <br /> and/or install the work herein described. This applicatidn is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /917 7 S , R4 ENSUS TRACT ' <br /> 3� <br /> Owner's Name Phone ' 7-16 7 <br /> Address -� —.Pitye <br /> Contractor t s Name 0.rsyla•ti3; ,� License 79070 Phone $'S -24 a <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/-7 RECONDITION /_7 DESTRUCTION I T <br /> PUMP INSTALLATION L-/ PUMP REPAIR PUMP REPLACEMENT /7 <br /> O ther /7 <br /> DISTANCE TO NEAREST: ' SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �v <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable`Tool Dia: of 'Well Excavation <br /> Domestic/private . r : Drilled Dia. of- Well Casing <br /> Domes't16hublid ,. Driven, Gauge of Casing <br /> Irrigation' n Gravel `Pack '-Depth of Grout Seal .. , <br /> Cathodic Protect_i_ on Rotary Type of Grout ' <br /> Disposal Other Other Innformation <br /> Geophysical Surface Seal Installed By: � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,.REPAIR: State Work Donee <br /> UE&TRUCTION OF WELL,: r Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations .of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well'-construction. Within, FIFTEEN DAYS <br /> after` completion of my work on a new well, I will furnish the San Joaquim Local Health District a <br /> WELL DRILLERS REPORT of the well, and notify them before putting the..well. in.use.. The above <br /> information is true to the•best -of my..knowledge and belief. I WILL CALL OR A GROUT INSPECTION <br /> FPRIOR TO GROUTING D FINAL INSPECTION. <br />' SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> k APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E II F AL INSPECTTON <br /> INSPECTION BY DATE INSPECTION , DATE <br />